09070131CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10511 BEARDON DR I CONTRACTOR TNW T/, �'"""'iD I PERMIT NO: 09070131 1
OWNER'S
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Li.. #(Q'�L_'5 �j^ 0
Contractor L-o-1-- �6ili�"t.�-R Date 1 1 10 J O
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this pennit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18,
Signature
Date -1 I 1 gi I Z0 \ o
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
PHONE NO:
BUILDING PERMIT INFO: BLDG r ELECT r-11 PLUMB r7
MECH r RESIDENTIAL r_i COMMERCIAL I -
JOB DESCRIPTION: ADD BEDROOM/BATHROOM(983), ADD PORCH
(246)REMODEL KITCHEN(135)&1/2 BTH(64'). CONVERT
(E)GARAGE TO LIVNG & ADD DETACHED GARAGE(432') NO
Sq. Ft Floor Area: I Valuation: $200000
APN Number: 32630177.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM CAtCLLE%D) INSPECTION.
Issued 3 V Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
: _l 115 UVO
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO BUILDING PF,RMIT
BUILDING ADDRESS: 10511 BEARDON DR
CON-I'RACTOR: LOZA
PERMITNO: 09070131
CONSTRUCTION INC
OWNER'S NAME: SRISURESH
- I -
BUILDING PERMIT INFO: RLDG ELECT PLUMB
License Class Lic.11
r f j—
*V1ECi1 RESIDENTIAL CONLMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: ADD BEDROOM/BATFIROOM(983'), ADD 13ORCI-I
(commencing with Section 7000) of Division 3 of the Business & Professions
(246')REMODEL KITCHEN(l35')&I/2 BTI-I(64'). CONVERT
(E)GARAGETO LIVNG & ADD DETACHED GARAGE(432') NO
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
3-22-22 REVISION 4 1- REVISE KITCHEN LAYOUT, CEILING
I have and will maintain a certificate of consent to self -insure for Worker's
RGLOCATC WALL- ISSD 4/13/I 1
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $200000
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 32630177.00
Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. 1 agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Issued by: Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature Date
All roofs shall be inspected prior to any roofing material being installed. If a roof' is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ ONVNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
Signature of Applicant:_ Date:
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR RET-'ER
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
IIAZARDOUS MATERIALS DISCLOSIIRF
construct the project (Sec.7044, Business & Professions Code).
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth & Safety Code, Sections 25505, 25533, and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Ilealth & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued,
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance, as provided for by
the Ilealth & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Owner or authorised agent: Date:
1 certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, 1
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this penmil: is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
1 certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCIIITF,CT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting ofthis permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date